The ED as a social construction, and some personal notes

I’m interested in sense-making and cross-silo collaboration in complex environments. Despite these topics simmering inside of me for about a decade, it took time to articulate these interests into a short coherent sentence. The seeds were planted in 2006, whilst working on an oil platform as a medic, and it kept growing as I continued reading, experiencing and learning e.g. doing an MBA and a BTech Management. Eventually, it culminated into one study a PhD allowing me the opportunity to explore sense-making and operational decision-making in Emergency Centres (EC) as complex environments.

I chose a few public hospital ECs, all situated in Cape Town. The study was divided into two main parts, first a description of the ECs detailing and comparing policy, procedure and daily happenings.  After that, I explored how people make sense of their complex environment e.g. how and when they share of information, level of collaboration, trust, communication and beliefs regarding other disciplines and management.

The social constructionist stance

The research was approached from a social constructionist view; I argued that the EC staff create their own reality and that knowledge is generated and shared via social processes. Thus, social relationships shape how the team or workgroup experience their situation/reality. Management literature describes social networks to be a key determinant of resilience. In turn, resilience is a vital characteristic of high-reliability organisations (HROs).

Linking stories and culture

People interact by swapping stories and sharing their account of events.  Some of these accounts are repeated and in time it is accepted as truth, demonstrating how things happen ‘here’. In a way, it becomes a self-fulfilling prophecy – because people are more likely to see what they are scanning for whilst disregarding some other aspects in the environment. Newcomers are rapidly introduced into how things are done and what to notice and what not i.e. the culture of the workgroup. The culture is reinforced via daily rituals, communication, and anecdotes.

The underlying beliefs (and culture) determine vital interactions e.g. level of engagement, the ‘allowed’ social networks, level of transparency, trust and sharing between peers, other disciplines and those holding positional power (management).

For example, if the prevailing story is that management is ‘out to get people’ or that management cannot be trusted – the operational staff will protect themselves by withholding information and will not report minor mishaps, errors or events. For as long as the prevailing story sticks no progress will be made to introduce a safety culture, create transparency in relationships, etc. The grapevine and informal networks in the workplace are the gatekeepers of the culture.  And as mentioned earlier, these social relationships directly impact on the resilience and reliable functioning of the EC. Studies show that people are more likely to accept organisational stories by face value, favouring plausibility over accuracy.

As Nietzsche wrote:

Madness is rare in individuals – but in groups, parties, nations, and ages it is the rule.

The organisation is socially constructed

The EC is a social construction that is dynamically and collectively shaped by all working in the EC. Those holding positional or personal power have louder voices and are more influential than those with less voice. Those holding personal power may yield their influence to block change e.g. improvement projects that are driven from the top-down or hindering cross-silo communication.

Why it matters

Essentially sense-making is about how abnormality or fluctuation is noticed, whether this information is shared, and what happens next – the subsequent decisions and actions. Gaining insight into how sense-making occurs in the EC provides crucial knowledge about the more obscure factors that determine operational efficiency. It also provides information regarding team dynamics, communication methods, and cross-silo collaboration.

Exposing deeply held assumptions

Tapping into the underlying assumptions that inform sense-making is not straightforward; assumptions are accepted as regularly reinforced truths, and the dynamics are not obvious, not even to insiders.  These deep beliefs are a constraint to sense-making in the EC.  When it acts as an enabling constraint it ensures collective sense-making, effective decision-making, reliable operations, and social cohesion.  Alternatively, when deep beliefs act as limiting constraint, it results in failed collective sense-making, poor decision-making, operational failure, and strong silo mentalities.

Exploring sense-making

To recap: the people in the workplace hold deeply ingrained assumptions, that they are mostly unaware of.  These assumptions directly impact the level of collaboration, situation awareness and their ability to respond to variation in their environment.

So, how do we expose these assumptions? By exploiting the organisational stories told.

Language and stories are essential tools that shape how people understand the world (or workplace). The understanding created is reshared by sharing stories and knowledge, and by using specific words and phrases the storyteller can emphasize certain facts whilst ignoring others.

For part two of my research, we captured the stories that the people in the EC tell about their daily experience, hearing all voices equally. This was done by using the SenseMaker® tool – proprietary to Cognitive Edge to capture the stories.

Capturing stories

Using SenseMaker®, after telling us a story, the participants answered a series of questions based on the theoretical basis from the fields of collective and organisational sense-making, especially those that explored catastrophe, crises, ambiguity and time-critical decision-making.

This allowed for a comprehensive data set via a novel way of combining stories (qualitative data) with self-analysis (quantitative data). The data was then visually displayed allowing easy visualisation of patterns or clusters of responses.

What I liked most about using SenseMaker® is the self-analysis – participants provided information regarding the meaning of their story, distancing the researcher from the initial analysis.

Utilising the stories to effect change

Roughly, the stories can be divided into two extremes: those stories that promote sense-making and collaboration and those that don’t.  By shaping the daily stories in the direction of those that promote sense-making, the underlying beliefs and assumptions can shift, creating a new reality or situation. In time this may lead to a different experience of the workplace, (hopefully) improving relationships, decision-making, and cross-silo collaboration. This can be continuously tracked by using SenseMaker® as a monitoring and evaluation tool.

Personal impact

I plan on journeying more into sense-making, narrative methods, and complexity. I have a special interest in the gaps and overlaps between disciplines and cross-silo work as I deem it the space presenting the greatest potential to disproportionately improve systems and processes. By impacting the level of social cohesion between disciplines, the ability to continue functioning despite major flux or challenge is immediately improved, leading to resilience.

I intend on discussing my PhD learnings and its applications to the health industry, yet the unintended personal consequence is that I realise that I cannot limit myself to working only within Emergency Care or even healthcare. It’s time to spread my wings a bit wider, and in future blogs, the focus will shift a more towards complexity, culture, team, collective sense-making, communication, and management.

I’m in the process of revamping my blog site to be more aligned with these topics, and I hope that you (the reader) will continue supporting the new angle.  I thought it apt to end with the words of Winston Churchill. Even though WW2 only ended in three years later, the battle of Alamein in 1942 marked the turning point in the war and it was after this battle that Churchill spoke these wise words.

Now, this is not the end. It is not even the beginning of the end.  But it is, perhaps, the end of the beginning.

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Sense-making in Emergency Centres

Interruptions, incessant multi-tasking, mobile equipment thus continuous reconfiguration of the physical space, noise, people, flux….

How do people that work in emergency centres know what’s going on? 

How do they make sense of what’s happening, who do they talk to and then what happens? 

How does the formal processes e.g. policies and procedure enable (or disable) them from responding to expected and unexpected challenges? 

Exploring the above has consumed me for the past few years.  Using a multi-layered research design, I’ve studied five large busy government emergency centres in Cape Town.  First was an ethnographic study, and it was utterly fascinating to take an outsider stance, observing and ask naive questions about what’s happening and why things are done in specific ways.

To understand the formal systems doctor and nurse policies, procedures and rules was studied, and the managers was interviewed separately.  External managers e.g. human resources, finance, risk, bed flow was also interviewed.  This part of the project was largely influenced by Karl von Holdt’s work on South African government bureaucracies; Schein’s on culture, Weick and Sutcliffe’s high reliability organizations and Klein’s naturalistic decision-making and macrocognition.

This was followed with a SenseMaker® study.  EC doctors and nurses were invited to share a story; after telling it, they answered a set of specially designed questions.  The questions were based on a fusion of two sense-making theories; Karl Weick’s process of collective sense-making in organizations and Gary Klein’s data/frame model of sense-making.

The SenseMaker® tool provided me with a double set of data, the questions are quantified and visually displayed so that we can easily search for patterns and then a narrative analysis will add the final layer of insights.  For this part of the study I extensively relied on David Snowden’s methods, both the SenseMaker® tool and conceptual Cynefin framework was developed by him.

I’m planning a series of blogs discussing my work of the past few years, watch this space for more regular blogs from now on!

And on Thursday I’ll be presenting a teaser of the SenseMaker findings at the 4th African Conference on Emergency Medicine in Rwanda #AFCEM or http://www.afcem2018.com/

 

Emergency care…just like reality tv, not aviation

To any observer, the Emergency Centre (EC) appears chaotic. There is an endless in-flow of patients, all with different presentations, complaints and needs. Often the sicker ones that require admission are stuck in the EC due to (amongst other reasons) limited available beds in the rest of the hospital. Thus, the EC remains responsible for non-routine, acute cases whilst simultaneously functioning as a multi-disciplinary inpatient-ward accommodating routines for surgical, medical, psychiatric and gynaecological patients. Adding time-critical pressure to prioritize and manage life-threatening conditions makes for some complicated challenges in this part of the hospital.
Shifting gears
In January I found myself working on a reality television show called ‘I am a celebrity, get me out of here’. On this show a group of celebrities live for a few weeks in a constructed basic campsite in a jungle. They compete in challenges for food and other items for the camp. Each week one of the celebrities are evicted based on votes by the viewing public. The winner becomes the King or Queen of the jungle.
On set, it’s initially tricky to get your head around things e.g. all the radio channels and knowing when and how to communicate, the rapid changes and the variety of roles. Meanwhile, in the control room, there is an entire wall full of screens with the non-stop live stream of information and rows of people working with the raw information of what is happening in camp and during the challenges.
Yet, when watching the show, all the little bits somehow comes together in one coherent whole. Observing how things work behind the scenes, I more than once felt that there’s parallels between reality tv and the EC. I could see more similarities with reality tv than some of the other industries like manufacturing, aviation and formula 1 that healthcare has been learning from.

 

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The control room

Similarities
Too much information and it is constantly changing
Both have too many streams of information with various communication channels. This implies that everyone is not privy to or able to access the same information. With the oversupply of information people function by consistently blocking out ‘unnecessary’ information. Not receiving the same and the oversupply of information carries obvious risks for miscommunication or missing out on important information that was perceived as ‘white noise’.
Unpredictable behavior
In both industries there is limited control over the trajectory and the outcome. The participants (celebrities) and patients are unpredictable and have the power to change the storyline or treatment plan and can subsequently influence the desired outcome. Every situation is influenced by the interactions, dependencies and relationships between the people. Interactions and negotiations take time and can’t be rushed to fit the schedule.
Emergence
Due to the unpredictability, situations unfold as it is happening. This is called emergence and it requires the ability to constantly adapt to new circumstances. The expected trajectory cannot be set in stone and linear step-wise rules cannot be applied. It’s better to respond to emergence in a flexible way, basically real-time editing to the situation. The most efficient way to deal with the constant flux is permitting the people on the ground to respond and act on situations as they deem fit.
Fairly unscripted
In both each ‘scenario’ has a basic guideline. The reality tv hosts have a script, there is a plan and layout plans for camera’s, lighting, etc. In the EC we have typical presentations with algorhythms and triage policies. Despite the script and typical presentation, we can’t force all chest pain patients to describe their pain as an elephant sitting on their chest with pain radiating into the left arm. So, in both the tools (scripts, plans, algorithms) are guidelines and not rigid rules.
Time-critical
There is a time-critical element to both. And even though there is real-time editing, there is a time-critical limitation on the number of chances to get it right.
Different roles, tasks and goals but same end picture
In both, the different roles function independently with different reporting streams and hierarchies. At times the roles/functions are not aware of the reality that other roles/functions are facing. This can lead to conflict between disciplines on the best way forward. Even within the roles, there is a degree of independence e.g. two camera men on the same set have different views of what is happening.

 

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To wrap
Both industries are complex and the separate entities within them are also complex e.g. camera, sound, nursing, medical etc. These separate entities overlap and respond in various ways even within the same situation. They thus co-create the current state and what will happen next is unknown. Here, daily life is routine, yet non-routine, time-critical and constantly changing.

More about what we can learn from each other at another time. I’m in EM…get me out of here!

Valedictory speech Prof Di McIntyre

‘A Universal Health System for South Africa, some final words on the NHI’ – the title of Prof Di McIntyre’s valedictory lecture.

It is long; however, it is worth the listen if you are interested in the South African Healthcare system, the NHI and where we are now.
Prof McIntyre was part of the team that launched Africa’s first Health Economics Unit (HEU) and she has published, advised and collaborated widely. I have been reading and following her work as well as others at the HEU for the past few years
Valedictory lectures are often used as a reflection, Prof McIntyre used her valedictory to make an appeal to the Minister of Health regarding new committees and a potential change in direction of the proposed NHI. In her speech she states that
“I’m appealing to the minister because the minister is the person who can change this. He’s the one who put out the gazette with the different committees. They have put it on hold and they’ve now invited additional comment until the end of November. He can stop this. He can stop this insanity.”
She touches on other issues including how managers in public healthcare are incapacitated by the system to manage effectively. She also mentions that we require more community health programs to increase access to care. I am hopefully posting another blog on EFAR soon (a community first aid response system).
I also thought that her comment that over-servicing in the private health sector is rational economic behavior interesting and will be reading more on the topic.
Please have a listen

Stories matter, we should tell our stories

Everyone has a story, every story is different.  I am currently data collecting for my PhD and speaking to various role players in the EC.  This TED talk reminds me that there is never a single story about any place e.g. the EC in the hospital, the hospital, the health system.  We all have our own story…and every single person’s story matter…and that everyone’s voice should be heard….

Lean nursing: a foreign concept in EC and ICU?

“Here is Edward Bear, coming downstairs now, bump, bump, bump, on the back of his head, behind Christopher Robin. It is, as far as he knows, the only way of coming downstairs, but sometimes he feels that there really is another way, if only he could stop bumping for a moment and think of it. And then he feels that perhaps there isn’t.”                                                                                                                            – A.A. Milne, Winnie-the-Pooh

Recently I started doing some in-hospital shifts again. Since my first shift, I’ve been pondering whether I should say something or if I should just suffer in silence. This blog is about my experience in one private hospital group. I’m well aware that, by posting this blog, I’m exposing myself to not working in said hospital group again. So, why risk future shifts and cash flow by posting this blog? Because I feel that I have to be true to me and what I stand for. And I don’t think that these experiences are specific to the hospital group or applicable to only nurses.
It’s my experience that most nurses working in hospitals feel like Edward Bear: they have a feeling that maybe their working conditions could be different, that there should be another way than the daily struggle that has been normalized. Maybe because I have worked outside of the industry, and as manager within the industry, I know that the daily conditions of clinical nurses can and should be different.
In his book Lean Hospitals, Mark Graban says that healthcare providers often think that our job or the value that we bring to the hospital is our ability to deal with problems and just work around the issues and get on with things, to improvise and cope. We think that it makes us heroes to go home broken after a tough shift. We do things that should not be done; we work hard at the workarounds that adds no value to the facility, to us or most importantly to the patient. I think that it’s especially true about nursing. Here is why:
1) Inefficient systems and waste within nursing
After being involved in LEAN projects, I look at most nursing processes and see them as beyond absurd. The amount of waste, workarounds and the inefficiencies are downright ridiculous. There is much more to LEAN than it being a process improvement philosophy, but I’m going to describe it as that for now. I do think that the LEAN approach at times tends to oversimplify complex issues, but it’s generally a good approach for linear problems. LEAN thinking categorizes wastes (inefficiencies) in the system that any organization should attempt to reduce such as:
The waste of unnecessary motion: Walking up and down to fetch medication, equipment, linen, water, bedpans, etc. are not always necessary. I’ve been tracking my kilometers walked per shift. My average over 2 months is 5.2km per 12 hour shift. To walk 5.2 km on a flat surface takes about an hour, implying that I spend one hour a day walking, not nursing. Most of my shifts have been in ICU, where the patients are within close proximity to each other and the ‘specialized nurse’ is supposed to be mostly at the patient bedside. Thus, one would expect that ICU nurses walk less than nurses in other units. So how much time do nurses in, say, surgical units spend walking versus nursing?
The waste of waiting: I also work in the emergency center (EC). A well-described concern in ECs across the world is access block. Yet, from a nursing perspective, there seem to be more constraints keeping the patient in EC, than processes that enables the flow of patients through the EC. The EC is at its busiest after hours and on weekends. Yet, this is typically when other services in private healthcare slow down and operates on skeleton staff– including radiology and pharmacy. Inevitably, the EC nurse becomes a gatekeeper for these systems, e.g. the EC nurse needs to call the radiographer prior to a patient going to X-rays. This increases the workload on the nurse and waiting time in the EC, and not to mention that after hours the patients are only allowed to X-rays one at a time.
The waste of overproduction: Again in EC, we overdo the administration. Why, for a follow up patient that only needs to see the doctor for a quick checkup requiring no nursing input, does the nurse need to complete a 4 page document? And, for admission, does the nurse need to copy 8 pages of nursing notes and the doctor’s notes? I know it’s for auditing purposes, but what is the value? With only one printer shared amongst EC and reception staff another delay is created for no obvious reason.
To transfer a patient from ICU to the ward requires similar overproduction of nursing notes. There is the implementation record, the transfer record and the ICU chart. Then, there is the ward documentation that some wards insist that the ICU nurse should complete. Again, overkill. Ordering simple blood tests is another complicated process. The doctor writes up the request (this can be on one of two places, so the nurse better check both!). Then, the nurse ticks it off on the blood request form, writes the bloods, patient name and bed number into a diary for pathology and has to write it into her notes. Re-writing the blood request that might be written in two places into three places increases the chances of error or omission of a test (and it happens regularly, especially when the unit is busy).
The waste of overprocessing: Overprocessing means doing things not wanted by the client. In the EC, the patient is required to sign out at two places before they can be discharged (creating a delay): once to say that they did not handover any valuables or received them back and then to agree to discharge. Asking why we need to do this, the answers varied between ‘it’s the hospital’s rule’ ‘its proof of our input, should the patient complain’ and ‘it’s for auditing purposes’. Considering the risk/benefit profile, is it really true that the risk of a patient complaint is worth the time lost and the compromise on patient flow?
And why do the nurses need to rewrite everything that the doctor wrote down? Would a simple nursing checklist on the doctor’s notes, especially in EC, not improve patient flow?
2) Conflict between job description and client expectation
Patients in private healthcare often state that they are paying a premium for the care that they receive and, as such, they have a right to demand a certain level of care. More often than not, the nurse is responsible for meeting these patient demands. Often, these requests are in conflict with the described nursing functions. In a way, this has created a reverse incentive, where, if the nurse meets the patient’s demands, then on paper it will appear as if the nurse didn’t do their job. But, meeting the job description and doing the job on paper means not meeting the patient’s expectations. Is the exhausting paper trail that nurses must leave (which, it seems, is mostly for auditing purposes) really patient centric and valuable?
It’s a core nursing function to coordinate all other service providers (e.g. physiotherapy, dietician, food requests, and radiology) and all of these services have preconceived ideas of what the nurse’s function and responsibility is. So, it is not surprising that nurses’ end up feeling pulled in every direction and is consistently told that they are not meeting someone’s expectation of what they were supposed to do that day.
3) Doctors behaving like toddlers
Doctors still throw their toys out of the cot…and nurses are still required to pick it the toys. I count quite a few doctors as close friends, so I felt apprehensive making such a blanket statement. But, hear me out – there is no formal process that prevents doctors (and other service providers) from behaving poorly towards nurses. When I worked on the cruise ships, there was a guest vacation policy. Guests could be asked to disembark or leave a public space if they behaved rudely towards the ship’s staff. Perhaps hospitals need to implement a similar kind of policy for inappropriate behavior towards nurses. Nurses are at the core of service delivery in private healthcare and, as such, the hospital and nursing management should ensure the psychological safety of their nurses.
On a recent shift, a doctor behaved poorly in front of patients, visitors, and other staff by shouting at a nurse. He had the nurse in tears for something that was completely out of her control. When he eventually left, even the patient was in tears. How is this patient-centered? And, why should the nurses still be expected to cover for this type of behavior, smooth things over and apologize on behalf of the doctors to the patients and their families?
Another LEAN principle is respect for people…nurses are also people and should be treated as such.
4) My time is valuable
This has probably been the toughest part of returning to clinical nursing. Covering the unit is the most important aspect of a nurse’s life. Family events or plans after work simply need to be adjusted according to the unit’s needs. Fulltime staff members’ shifts change regularly, sometimes at incredibly short notice. If a shift change happens late, the other shift just needs to stay on, no explanation needed. Even though a part of me gets that, a part of me also rebels against the frequency with which it happens.
As an agency nurse, there is the opportunity cost of being booked for a shift. The agencies have the right to cancel your shift up to 2 hours before your shift was due with no financial compensation. Yet, you probably said no to other work or gave up on other opportunities in order to be available for the agency. Taking into consideration that you are required to be on shift 15 minutes early and sometimes have a 30-60 minute travel time, they basically cancel you as you are already on your way to work. Not really fair….and, beware- should you cancel a shift, you are ‘punished’ by not being booked for a few days.
5) The absence of nursing leadership
There are good nursing managers out there. But, are they showing leadership and advocating for nursing care? As I’ve been told: you can see that the unit is busy because the unit manager is hiding in her office behind a closed door.
Why do they do hide? Are they ignorant of the issues on the floor? I think not. I think it’s more a case of the managers feeling as helpless and disempowered as their staff… and they are caught between the staff and the higher levels of management.
Again referring back to LEAN, ‘Go and See’ is crucial. What the nurses on the floor need is for the nursing managers (hospital managers, head office representation) to be there, to be involved, to produce policies that enable them to do their job, to remove constraints and workarounds, basically to operationally manage the unit. By going and seeing those positioned to improve circumstances can experience the current conditions and frustrations. Currently  they remain removed from the daily grind and they hide behind their audits, checklists and paperwork. Nursing and nursing management has become paper and audit driven rather than patient driven. Why this irrational fear of protection with administration?
6) Level of dissatisfaction
In the short time that I’ve been doing shifts again, I’ve really felt disheartened with the level of frustration expressed by nurses. Not to mention the lateral violence, where nurses take out their frustrations on peers or those lower qualified. I daresay that the lateral violence is a direct result of the daily frustrations with waste and inefficient processes, the behavior of doctors and lack of nursing leadership. There is very little psychological safety within the current nursing environment and, again, as someone told me: the managers don’t have our backs.
The LEAN philosophy describes another waste: the waste of human potential. It’s my belief that the current hospital environment wastes nursing potential and therefor is losing great nurses.

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Summary
A quick unscientific Facebook stalking of my university nursing friends revealed that maybe 3-5 of them are still clinically nursing in hospital. Something must be wrong. Especially seeing that people love telling us that nursing is a calling. If that is true, then we all seem to have lost our calling…
Or, is it that the environment has become so detrimental that nursing is no longer appealing or sustainable as a long-term career option? I wrote this blog because I believe that we can and should change the environment. But, it will take strong nursing leadership. Step one of being the patient’s advocate is by being a nursing advocate, advocating for better nursing conditions so that we can be better patient advocates.